headache Flashcards
how many visits/yr
13 million visits annually
Brill usually starts with tylenol or ibuprofen
what percentage of ER visits
serious?
4%
1%
pathophys: Irritation of pain-sensitive intracranial structures
Large arteries
Venous sinuses
Trigeminal nerve (5th cranial nerve)
pain-insensitive structures
Choroid plexus
Brain parenchyma
Ventricles ( ependymal lining )
( attributing to little or no headache mass lesions
painful stimuli arising from brain tissue above the tentorium cerebelli are conveyed by the
trigeminal nerve
primary
Tension-band like
Cluster-in/or around one eye
Migraine-28 million americans
sinus: behind brows
secondary
Stroke Trauma Brain lesion Cocaine Sinus Disease
migraine ha
Episodic Headache Associated with Gastrointestinal changes* Neurologic* Autonomic* Unilateral*
One of the three is necessary for the diagnosis ? + 1 phobia
Pulsating; Unilateral
Frontotemporal
migraine sn
Phono-phobia Sound sensitivity
Osmo-phobia Odor sensitivity
Photo-phobia* Light sensitivity
migraine timing
May begin in childhood- don’t give dx till 5 or 8
Peak ages adolescence and
Young adulthood
Greater in woman then men
aura
focal neurologic symptoms precede, accompany, follow(rarely) ha
-develops over 5-20 min
visual disturb.*
-language, sensorimotor, brainstem disturbance
migraine classes
Migraine With aura Migraine without aura Hemiplegic Migraine Confusional Migraine Ophthalmoplegic Migraine Basilar Migraine
complicated migraines usually have..
Major neurologic dysfunction
( hemiplegia and coma )
admit*
basilar migraines usually…
Primarily in children Episodic headache Signs of ..... Brainstem dysfunction Cerebellar dysfunction (Dysarthria, diplopia, ataxia)
aura ddx
Seizure
Transient ischemic attack
cluster ha
Intense steady and unilateral Temporal location (trigeminal cephalgia) Associated with Nasal congestion Conjunctival injection Ipsilateral forehead sweating Men > Women Late in life onset Rarely in childhood Attacks often awaken patients “Alarm-clock headache” Periods of frequent headaches are separated by headache-free periods of varying duration
tension ha
Most common ( primary ) Pressure feeling Not unilateral Frontal / occipital “Pain in the neck” Pain last for days
band-like
Pseudotumor cerebri
IC hypertension Worse with straining Diplopia Papilledema Abducens palsy
Pseudotumor cerebri
Thrombosis of transverse or sagittal sinus venous thrombosis
Chronic pulmonary disease
SLE
Uremia
Endocrine disorders
Drugs (tetracycline, vitamin A, OCP)
Idiopathic (most common): overweight women age 20-44
imaging
Ct brain without contrast to look for space occupying lesion
MRI
MRV
this confirms increased intracranial pressure
LP with opening pressure
tx:
Acetazolamide Topiramate Prednisone Weight loss LP Shunt Optic nerve fenestration Stop causative agent
migraine tx:
- Acetaminophen
- Aspirin
- NSAIDs
- Opioid ( limited use )-CI: rebound ha
5.Sumatriptan“triptans” (Serotonin agonist ) - Droperidol
7.Quiet / Dark room - Metoclopramide (Reglan)
(dopamine interaction )
tension tx
same + OMM
muscle relaxers: valium, diazepam
cluster tx
- Oxygen
- Dihydroergotamine
- Sumatriptan
(Serotonin agonist )
secondary
SAH
meningitis
mass lesions
intraparenchymal hemorrhage
SAH
1 in 10,000 headaches in the United States 1 percent of non traumatic headaches Normal findings *Thunder clap* “ Worst headache of life” Onset with exertion may have neck pain
mass lesion
70 % of tumors have “headache” as the initial presenting complaint
-look for brain metastasis
meningitis
Viral / Bacterial infection Fever Nuchal rigidity Kernig’s sign ( knee extension ) Brudzinski’s sign ( leg lift )
Intraparenchymal Hemorrhage
50 % of patients with IPH tumors have “headache” as the initial presenting complaint
Critical secondary causes requiring emergent identification and treatment
- Subarachnoid hemorrhage- need MRI, look for aneurysm
- Meningitis-start abx
- Brain tumors-increased ICP
start steroids if not resectables
Critical secondary causes not requiring emergent treatment
Brain tumor (without increase in ICP)
Generally benign and reversible secondary causes
Sinusitis
Hypertension
Post-lumbar puncture headache
Primary headache
Migraine
Tension
Cluster
how to tx LP puncture ha
typ. tx (NSAIDs, tylenol)
then caffeine
then anesthesia: “blood patch” over LP site, dec. CSF leakage
better when lie flat
Ha eval
pattern (worst?) onset (SAH) location assoc. meds comorb
assoc. symps
Visual changes
Fever
Seizure
Neck stiffness
meds that may cause ha
nitro
coumadin
comorbiditis
AIDS-fungal mening., cryptococcal
Malignancies
Coagulopathy-IC hem
Physical Exam red flags
Abnormal vitals Neurological exam Fundoscopic exam Kernig sign Brudzinski sign Temporal artery tenderness (scalp giant cell arteritis, bruits
prior hx of ha does not rule out…
and if tx and gets better, does not rule out…
serious pathology
same! could still be SAH
ha preventiaon
topamax, topiramate? valproic acid (seizure, mood stab, trig. neuralgia) candesartan propanolol timolol verapamil amitriptyline (antidep) botulinum toxin A butterbur-herb
ppx for ha that..
Headaches that occur more then two or three times a month
Significant disability with attacks
Alteration of central neurotransmission
ha ppx
Valproic acid Propranolol Timolol Verapamil Amitriptyline Botulinum toxin A Acupuncture
CT scan for….
before LP
Worst headache of life Abrupt onset Neurologic deficits Persistent vomiting Fever Trauma Loss of consciousness Altered mental status Sinus imaging
HIV
>50 w. normal neuro exam
if abnormal ???
get MRI/MRA with
Posterior fossa lesion (cerebellar issues)
SAH unable to perform Lumbar puncture
Venous thrombosis
persistent neuro deficit with tx
ha management
Identify the correct diagnosis of headache
Diminish pain associated with an acute attack
Prevent pain / associated symptoms of recurrent headaches
ha diary
- ID triggers
- monitor frequency
- involves pt
- Record response to treatment
signs that suggest pathology
Fever Nuchal rigidity Reflex asymmetry Altered mental status Papilledema
symptoms that suggest pathology
Worst headache of life Age over 50 Progressive Awakens patient-every morning, doesn't go away: mass Neurologic dysfunction
ddx ha
ocular: glaucoma
environmental: high altitude
metabolic: hypoglycemia
toxicology: CO poisoning (cherry red macula, can measure on ABG)
vascular: HTN
special pops for has
preggos: preeclampsia–>eclampsia: seizure
immcomp: cryptococcal (HIV)
kids: Dental infection
Sinus infection
Neoplasm
Febrile illness
read pages 954-958
in current
floaters aura photophob norm exam lay in dark with cold rag
UCG
repeat triptan dose
rest, darkness
sev. pain around left eye
tearing, congestion
cluster
sev. pressure-like
worse when bending down, stren activity
papilladema
CT, LP
pseudotumor cerebri
